NAN warns health care practitioners about dangers posed by EPHINEPHrine shortage

A National Alert for Serious Medication Errors (NAN) was issued yesterday by the American Society of Health-System Pharmacists (ASHP) and the Institute for Safe Medication Practices (ISMP), warning health care practitioners about dangerous medication errors that could be caused by a shortage of EPINEPHrine pre-filled syringes.

The alert was prepared as a caution to health care organizations and practitioners even though there had been no reports of deaths or serious errors at that time. However, days before the alert was finalized, news media in Bangor, Maine, reported the death of a hospital patient from an overdose of EPHINEPHrine. It is unknown at this time whether the EPHINEPHrine shortage was a factor in the deadly error.

The NAN warns health care practitioners about dangers posed by this drug shortage and includes recommendations to prevent medication errors that could result from the shortage.

The NAN was developed by the American Society of Health-System Pharmacists and the Institute for Safe Medication Practices to help bring an end to deadly medication errors. Physicians, pharmacists, and nurses are expected to use the recommendations to take immediate action to prevent serious medication errors at their facility.

Alerts are issued by ASHP and ISMP only when a significant risk for serious or fatal errors is detected through ISMP's Medication Error Reporting Program (MERP) and the alert is distributed by the National Council on Medication Error Reporting and Prevention.